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HomeMy WebLinkAboutBuilding Permit #058-13 - 326 FOSTER STREET 7/17/2013 n.A TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION hh ,. Permit NO: f✓ Date Received Date Issued: _ EMPORTANT:Applicant must complete all items on this page LOCATION a . Eoris 7 Print PROPERTY OWNER 19/1 IV D 11Z Z CAC,lei a Unit# l Print MAI'NO: PARCEL:6)2/ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure ye no 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 DSeptic ,�Well'. ❑Floodplain �tWetlands` ❑; ersedDistnct Water/S ewerr 1_ _ f DESCRIPTION OF WORK TO BE PERFORMED: /A VI n� �� �2�K �°L tc .r� I 1 -2 5 Tw kd l F�LG (Identification Please Type or Print Clearly) OWNER: Name: Q A- Ae jO CZZLk C, m Z,6 Phone: Address: 3 --2-6 l� A-e7 TsLiL. S r t CONTRACTOR Name: iy, r_ S Tar, gh'S 1&-A:e Phone: °�7 0-4 Address: T 21,6 L. �A Supervisor's Construction License: 009 !T :)-$ Exp. Date: Ll- .Home Improvement License: I G2 !ZG -7 Exp. Date: '7- 2L - /z ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. . Cha Total Project Cost: $ 07 FEE: $ Check No.: e3­4_0 Receipt No.: Np�E er, ons o f acti with unregistered contractors do not have access to the guaranty fund nature.of Aae Signature of:contractor Location y J� �_ S r— I Y ' -�-, Z No. - Date • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ K Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBody Art ❑ 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 I 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 1 t DPW Town Engineer: Signature: n Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 1.24 Main 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 NOTES and DATA— For department use t� bb 6f4- El 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 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) a 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 MOTE: 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: Doc.Building Permit Revised 2008mi /17/2013 09:29 9785319442 :4850 P. 001/001 tea' CERTIFICATE OF LIABILITY INSURANCE DATE(W4/D°'Y`YYY) 7/17/13 HIS 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 AppI110NAL 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 endorsemenls)_ PRODUCER -CONTACT Kilgore Insurance Agency NAME! PHONE -- -- - � _...---------- ----•-- 5 Centennial Drive ' (478) 531-6550 I (AIGX No),, (978) 531-9442 Peabody, MA 01960 Ab'M$S: INSURBR(S,AFFORDINGCOVERAGE NAICs .. ....-..._.__..—_.__.... _.—......_..---.. ... .. .-_--..__—_-...-.-..._......... ,INSURER A_.Wes tern World Tnsurance INSURER C:Travelers ,Property & Cas - INSURED INSURERB:-Safer _ Tnsu_ranC_e Comp •,an —__—_____•. New England Custom Design -- Ron Weinberg 226 Lowell Street / Unit B4-A INSURER E: ^M Wilmington, MA 01887 INSURI.ER F: 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. - -- —— _ ILTR TYPE OF INSURANCE ANSR�SM POUCY NUMBER MMIOICONEY I MMIUD�YEYW I LIMITS A GENERALLIABILI7Y Y INPPI3451227 3/14/13: 3/14/141 EACHOCCURRENCE— X! COMMERCIAL GENCRAL uAHII IfY• DAMAGE TO RENTED ..___.....-- • ,- CLAIMS-MADE X OCCUR MED EXP(Anyo a persm) I$ 5 000 ...... .......... ..._.. i _PERSON4LSADVINJURY :.a . . t_..._... _........._..._.._..__.._..... I i GENERAL AGGREGATE,_ - $—I�OOO�OO,O,••• GEN'LAGGREGATE LIMIT APPLIES PEP, I PRODUCTS-COMPIOPAGG $ _ 21000•,.000 POLICY I PRT I LOC AUTOMOBILE COMBINEDSIN 4/5/13' 4/5/14 GL h I a Y :5054921 ANY AU rU I BODILY INJURY(Par parson) $ ALLOWNED X SCHEDULED _.._._____.._._. _._..__..250.000 .. AUTOS AUTOS DODILYINJIIRv(Paraccirlanl) $ _ 500 000 NON-OWNED PROPS RTY DAMAGE HIREUAUTUS _ AUTOS :(Peroceionn:) _._.--TOO OOO _......---..... _.... . r UMBRELLA LIAB OCCUR EACH OCCURRENCE - —1 $..._..--................ EXCESS LIAR—_ CLAIMS-MADE AGGREGATE S DED RETENTION S I S C WORKER:COMPENSATION 7PJUB-0239N23-2-13 3/14/13 3/14/141 WC STATU. I I OTH- AND EMPLOYERS'LIABILITY YIN /WY PROPRIF.TOR)PARTNER/EXECUTIVE F.l_ EACH AC CI DE Ni S 10O 000 OFFICtiMEML+EREXCLUDED? N ,NIDI i !......._...-- (Mandatory in NH) I -• ._. EL.DISEASE-BAEMPLOYEEI 's 100'.000 (ryyas.09Scribaundai i i ..:.------------•' ......-.------i.__.._...... 0 SCRlPT!(IN OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT, $ 51210,000 I I ! I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Rernarks Schedule,if more space is rt qti rad) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS, Building Department VIA -PAX - (976) 688-9542 AUTHORIZED REPRESENTATIVE North Andover, MA _. _ . Cyrus A. Kilgore �0 / �K D ©198$-2010 ACOR CO RATI N. l rights a Alerved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phooe: Fax: (802) 786-6844 E-Mail: NEW ENGLAND CUSTOM DESIGN, INC. 226 LOWELL STREET WILMINGTON,MA 01887 #978-658-0881 Home Improvement Contract Registration No. 102467 ROOFING AND SIDING AGREEMENT This is a legally binding contract.Make sure you read this Agreement and understand it before signing it.Do not sign this contract if there are any blank spaces. NOTICE:All home improvement contractors and subcontractors,unless specifically exempted by Massachusetts law,must be registered with the Commonwealth of Massachusetts.All inquiries about registration should be directed to: DIRECTOR-HOME IMPROVEMENT CONTRACTOR REGISTRATION One Ashburton Place,Room 1301 Boston,Massachusetts 02108 Telephone:#617 727-8598 his Agreement i n —20/J ..by and between New England Custom Design,Inc.(hereinafter,"Contractor") id owner 4,45 (hereinafter,"Owner"),of yV ity/Town 0 h�i 1°9/r/�7!tG� State lWa_ Zip (�Phone &---12-,4,2V&---12-,4,2V-a//V )b Address("The Premises") (#)Phone G8`S ELrt l Doors:Number Type tyle Color Q Windows:Number /U Type &14d�� r tyle Color - Shutters:Number PR Cb/for Style Where Aluminum Gutters:Color Where Aluminium Leaders:Color Where Remove existing gutters and leaders? Where C7 EMARKS/EXTRAS:Missing or defective lumber is not included in any category of work unless specified here. The Con *1agrrees�to perform lin agoo`d aand> �mannerall vvm*detailed above CASH PRICE$ fI p�5'TJ C/` 00 Note`AU Ro tt " usto"mers + <4#w'= DOWN PAYMENT$^��3� DO S PAYABLE ON START OF WORK$ '^ New England G�lstom Design&1c,will n6tbe held iesponslile for dose and debns�a➢mgm t t- PAYABLE $ / acne areas dutii roo tnstallanon, X Elease PAYABLE ON COMPLETION$ g • remove or cove;valuables: i .�� t r ti DATE: 20IL RIGHT TO CANCEL to Owner may cancel this agreement if it has been signed by the Owner at a place other than the address of the Contractor,which may be his main office or branch thereof,provided that the Owner tifies the Contractor in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing ofthis Agree- !nt.See attached Notice of Cancellation.A cancellation fee representing 30%of the contract price will be in effect$cancellation is requested after the legally allotted time has elapsed. ie Owner hereby certifies that he has read this Agreement,that the terms and conditions and the meaning thereof have been explained to him,and that he fully understands them and that there is no s an betty e p 'es,verbal or otherwise,than that which is contained in this Agreement,and agrees that the said Contractor is not responsible nor bound by any representations not con- ned in this ement,made y any of its agents,unless the same be reduced to writing and signed by the Contractor. ITENTI HOMEO DO T SIGN THIS CONTRACT IF THERE ARE ANY BLANK ACES. %-) wner's Si atone Date N En Custom Design,Inc. Date wner s Signature Date NORTFj Town of . t E : 1j ndover O - .:�.. 0 No. LAKI- ® � Z oh , ver, Mass, • �� • �� COC H1Ch1WICK y1' S U BOARD OF HEALTH Food/Kitchen PER I L D Septic System THIS CERTIFIES THAT I. . . �T ...................... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .............� .Z.�i�........ .�..�f.. ...... ............. /�/ Rough to be occupied as .......is......Ao....... ... �........ .14!K•0/J..3.� Chimney provided that the person accepting this permit shall in very respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN §A0 THS ELECTRICAL INSPECTOR 34 . UNLESS CONSTRUCSTA Rough Service ................. .......... ..................6&M.............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE • I The Commonwealth ofMassachusetts - Department of lndustrlqlAccldiints Office of Investigations kvi 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): IV.•E_ 11 /7'l fiA4 16�v L /C• Address:_ 4 5� .T City/State/Zip:_ ,a . Q!&P Phone Are you n employer?Check the appropriate box: Type of project(required): 1. am a employer with_ 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.x El Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. g, E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]i employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they Aire 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:- "� J//,L A!:A— ' Policy#or Self-ins.Lie.#:__ Expiration Date: 73^ `/ j Job Site Address: ✓' �6 �' 3��� 3ity/State/Zip: 4",PeV'7-T )-7,7A Attach a,copy of the workers'compensation-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. Ido hereby cert( under tl e pains andpen lties ofperjury that the information provided above is true and correct. - Si ature: VDate: -7-1 Phone#: 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.CitylTown Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other - - - Contact Person: Phone#: Information and ffustruction's Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,• express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If anLL C or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' . compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials -Please be sure that-the affidavit lete-complete le p g ilii is-comp The De artmerifhas rovidect a s ace at the bottom Y: p P---• P--- of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only subunit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The GammonwoaXth of Massa cliustitts Department ofladustdal Accidents Mace of investigati,ona 600 Washingtou Street B oston?MA,021].1. Tel,#61.7-727-4900 QYd406 or 1:-877,MA.SSA.BB Revised 5-26-05 Fal,#617-727-7749 '[WrU V maces rrntr/Ain li ,p� �� �P ea�o�Civtaaaizctucae�. �\ Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR UelVgistration: 102467 Type:`' piration::-7d-2-044 Private Corporatio NEW ENGLAND CUSTOM DESCGN.INC. S 7Val Lanza 226 LOWELL ST WILMINGTON, MA 01887 ' 4 Undefsecretary i i I 4 Massachusetts -Department of Public Safety.:. Board of Bui ding Regulations and Standard8 .' Construction Supervisor, License: CS-008828 VA L J LANZA.� 34 BMY S) Q REVERE P4 02 S oJ +�►" �lt itxiA� Expiration' Commissioner 04/20/2014