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Home My WebLink AboutBuilding Permit #703-11 - 329 Middlesex 4/19/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO• 0 Date Received Date Issued: �IW-ORTANT: AptDlicant must complete all items on this naLye LOCATION Z �_,%�� S- / ► Print MAP NO: Historic District ye o Machine Shop Village ys no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ 9ne family ❑ Addition k7wo or more family ❑ Industrial ❑ Alteration No. of units: ?. ❑ Commercial ❑ Repair, replacement ❑ ssessory Bldg ❑ Others: ❑ Demolition Ila Other u o �.�k;! I ❑ Se t1C�. i❑�Flobdplain�Oi�Wetlandsi� ® WatershedlDstrict' r; �s its t . s j, jai ` 3y � {. - � ,i❑p tWaterYSewer ,t. �'_. __ ___ 31.x._.. _ _ s� _ 1+ !�'� , _ . R !Y ._:4Ffr e�f.- � -'t: T'ti".. �s�.{JV eA:_.'q nPSCRIPTION OF_ WORK TO BE PERFORMED:_ A Identifica 'on ,ye ype o Priu early) OWNER: Name: . / Phone: Address: � 9 Vlhw .� z? z CONTRACTOR Name: 4!9 % g�& &A/ ! • Phone: �?Z? Z z 1 7777 Address:-, Supervisor's Construction License: ,��3,� Exp. Date: //z, Home Improvement License: /o?Exp. Date: ARCHITECT/ENGINEER Phone: Address: . No FEE SCHEDULE. BULDING PERMIT. MOO PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ 77 �� FEE: $ 0 C Check No.: 6� Receipt No.: ( � Q�� NOTE: Persons contracting wit regi Rterecl contractors do not haven the guaranty fund M 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 o 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) ❑ Muss 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swimming Pools.- Tobacco ools Tobacco Sales ❑ Food Packaging/Sales El Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS DATE APPROVED 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: Signa Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes nn Located at 124 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.$10041000 fine NOTES and DATA -- For department use ® Notified for pickup - Date Doc:.Building Permit Revised 2008 Location —�3qi Mjl o(-ez No. d "" Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ F— Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Check #" 240/5 Building Inspector -GreaterLawrence Community.Action Auditor.' Renee Tofanelli Phone :978-857-784 Job # 38ZS. Date• Client Phone ,)use Type: I fam fam fam ... du lex 4 fair Sidi e; Wood Vinyl Alumn sb :Single Asb Dble Vin 1 overAsb ' T191 nc ./Stucco A Roof Type .Gable Hip Flat Gambrel Condition. -'Go od , Fair Poor Manufacturer:�(, L we L41n►r Phone 2 Cape . Ranch Victorian Colonial - enemen Condition Good air Poor shalt Comments: Roof Material Asphalt Slate Rubber Tar & Gravel CAZ Base Reading .: Pre Post : CAZ Worst Reading :.Pre Post:' FHW eam FNA Space Heater Oil Gas Electric Woo Pellet Coal Treated Ducts : - Yes No ,---Domestic Hot Water Tank Oil - Electric Tank less Gallons -�}D-- Temp Se Draft �j SpillageYes No Amb CO: �� Stack C : . Add 6 Feet of pipe Wrap j NO Commentsr, I" SA.Aa�;,V Print Out 7.5 % Efficiency__-- 26 ppm ExcessAir Time: �°g'1 11:24:02 AM Date: Stack Temp yo,g 04/08/11 Primary Temp Fuel Oxygen -7, Oil CO'.. 2 In A' 52.1 % CO Air Free.�,_ Flame Color 3/ Age Ambient CO Smoke Reading Referred to HWAP . Y Date referred Smoke Reading Draft -& ,, w 0z 7.5 % CO 26 ppm Eff 84.1% Cbz 10.0% T -SPK 408 `N T -AIR 66.7 ''F• EA 52.1 % CO (0) 40 ppm , Differential Pressure -0.04 inwc -v' AD%Lw Ambient CO Readings: Stove -Oven Broiler Dryer Ambient CO Readings: Stove c _ Oven' Broilers Dryer MVV - s Greater Lawrence Co0munit3'Action Auditor.- -Renee Tofanelli Phone: 978-857-7849 Job # 3829 Date: Client First: Ti.�JeT� L sf ::. - Address:.: 2 2 nd floo,y Cit Zip Code O/ X3.7 Zee Phone : 918 9%v�/c3/9 Phone 2 - - House Type:. Cape Ranch Slit 1 fain(2 fam fame duplex . 4 family Victorian Colonial enemen Siding .Type; Wood Vinyl Alumn Asb Single sb DbleCondition Good Fair Poo Yinyl overAsb T191 :Brick/Stucco As half Comments: Roof Type Roof Material . Gable Hip Flat Gambrel Asphalt $late Rubber ..Tar & Gravel .. Condition Good 'Fair Poor ' Heatin stem S 9' Y print out Manufacturer:/G%y�i�d Efficient CAZ Base Reading : Pre Post: Excess Air / ] S Time: 11:/U�11333:09 AM {f�/ a Stack. Tem 39Z . Date: Q4/1/ CAZ Worst Reading : Pre post: Primary.Temp Fuel Oxygen tc . Nat Gas 6w) Steam FHA Space Heater CO. 2 S:" Oil WGa�§ Electric CO L� Oa a, 3 Wood Coal CO Air. Free co 439 rpm Eff 81.0 % Flame Color. two CO2 8.3 % Treated Ducts : • . Yes No Agevpy�'S T'� 392 T T -AIR 67.5 T Ambient CO ., . 2 BA 38.2 % Domestic Hot Wafer .Tank Smoke Reading .4) co (0) 628 ppm Gas Oil Electric Tank less Referred to HWAP Y Gallons 40 Temp Setting Lc/ ,qtr Date refen'ed Differential Pressure Draft o Spillage Yes No Smoke Reading -0.02 inwe Amb'CO: 0 Stack CO:. Draft Add 6 Feet of pipe wrap ES / . NO Sp illage Comments: Ambient CO Readings: Stove c _ Oven' Broilers Dryer MVV - Office of Consumer Affairs & Business Regulation °HOME IMPROVEMENT CONTRACTOR _ s �- Registration: 141124 Expiration: 1/12/2012 {; Type: Supplement Card P, A+M GENERAL CONTRACTING INC. MICHAEL FITZGERALD 5 SOUTH RIDGE CIRCLE ��6--- -- LYNN, MA 01904 Undersecretary Department ill' Public "atctn ►;nand ut' Buildin,: Rc,ul.ttinn% and •tanii:u-d, NW �onstructicn Sup&visor Specialty License License: CS SL 99933 Restricted to: RF,WS,DM,IC MICHAEL FITZGERALD 9 WINCHEST COURT GLOUCESTER, MA 01930 --�— —�/ xpiration: 6/19/2012 umii,.i, n r T f" 99933 ll From:Susan Petro FaxID: Page 2 of 2 Date:324/2011 09:36 AM Page:2 of 2 OP ID: SM A ,Rb., CERTIFICATE OF LIABILITY INSURANCE DAT03124111 YY) 03124111 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 781-224-5700 Mazonson LLC www.mazonson.com 781-224-5777 701 Edgewater Drive Suite 230 Wakefield, MA 01880-6236 CONTACT NAME: PHONE Fax Ext): AIC, No E-MAILo ADDRESS: PRODUCER A&MGE-1 CUSTOMER ID 3 INSURER(S) AFFORDING COVERAGE NA # John Scanlon INSURED A&M General Contracting, Inc. -IC A: Peerless Insurance Co Norman Dube -INSURER INSURER B: ACE - USA 119R Foster Street Peabody, MA 01960 INSURER c INSURER D INSURER E MERCIAL GENERAL LIABILITY -0 -CLAIMS INSURER 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. INSR LTR TYPE OF INSURANCE ADDL INSR S B WVD POLICY NUMBER POLICY EFF MMfDDNYYY POLICY EXP MMlDDfYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 100,000 A1 MERCIAL GENERAL LIABILITY -0 -CLAIMS CBP8762001 03/20/11 03/20/12 -MADE ] OCCUR _ MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 —d GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG $ 2,000,000 �CEN'L,01.1L:,GR10A1ELIMITAPPLIESPER PICY PRG- LOCJECT A AUTOMOBILE LIABILITY ANY AUTO BAS762301 03/20/11 03/20/12 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJJRY (Per accident) $ X X SCHEDULEDAUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) $ X NON -OWNED AUTOS I V $ I X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 A EXCESS LIAB CLAIMS -MADE CU8762501 03/20/11 03/20/12 DEDUCTIBLE $ $ X RETENI"ION $ 10,000 _ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIE.XECUTIVE Y) N OFFICERtMEMBER FXCLUDED9 (Mandatory In NH) NIA 046275251 03/20/11 03/20/12 WC STATU- OTH- TORY LIMITS ER E L EACH ACCIDENT $ 500,000 lE,L DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CERTIFICATE HOLDER CANCELLATION i TOWNAN1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIIZEDDR �,'EPRRESENTATIVE 01988-2009 ACURU GVKI'UKAI IUN. An ngnis reservea. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD M O z rA rA Pi O N V V l"': : •dam Qt C C h'mm Q m c CD CE ;= O V• O � m :mt :rm 0 CL N c 0 O CJ �. E m c cp � �O CL= L I ` V o z3 Mo � r N c � � _ m i (n caz NCIO O CD -00 U mc -3 L m C/)N m c ''^^ • y=,,, y=... .0. CC) J • m C.2 h O `O Z c a ¢. W mm3 .o = m mt O N F- o vev� o o F- m COO c = m NJ O •O r _ r Ceo •... .� N. a= oc E = •c Z N O cC.3 o ® � c g COD CO _ a`y•� O _ 4- M. mm > 6 O u p w �+ a&i cn aa °w' G w o w U w a o u; G w a o. U. w o rsw CE G x o O w G w" W cR Z b cn - Q E cn Pi O N V V l"': : •dam Qt C C h'mm Q m c CD CE ;= O V• O � m :mt :rm 0 CL N c 0 O CJ �. E m c cp � �O CL= L I ` V o z3 Mo � r N c � � _ m i (n caz NCIO O CD -00 U mc -3 L m C/)N m c ''^^ • y=,,, y=... .0. CC) J • m C.2 h O `O Z c a ¢. W mm3 .o = m mt O N F- o vev� o o F- m COO c = m NJ O •O r _ r Ceo •... .� N. a= oc E = •c Z N O cC.3 o ® � c g COD CO _ a`y•� O _ 4- M. mm > 6 O LLI 0 LLI U) OG W LLI0 LLIW C4 O co L O s Z p. O Q h C � c cm h O o•- Q 'C — A �E O O m m 0 co � Q � o e_Cv a a cma y C *" C O O V —J'p 0 CD Z C O� V y C O C d h LLI 0 LLI U) OG W LLI0 LLIW C4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street r Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers DDlicant Information _ _ Please Print Le2ibl, Name (Business/Organization/Individual): Address: City/State/Zip:/0f Q Z,0A —O er Phone.#: Are u an employer? Check the appropriate box: 1. M I am a employer with 96 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. E li I a�n a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' insurance 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.n Roof repairs 13.[Other//l��i,/�i Tl0Al *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. $Contractors 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 must provide their workers' comp. policy number. 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. #: 6 ;2 Expiration Date: d Job Site Address: /2CJ�i� �. City/State/Zi. �04// 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 of this statement may be forwarded to the Office of Investigations of the DIA for insliance coverage verification. I do hereby certify and ins and ,fe ury that the information provided above s 7eldnd correct. Signature: Date: / Phone #: 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 5. Plumbing Inspector 6. Other Contact Person: Phone #: