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HomeMy WebLinkAboutBuilding Permit #502 - 33 WEST WOODBRIDGE ROAD 3/25/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: i Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑ Addition ❑ Two or more family El Industrial - 4'Alteration t� No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 1el;ds�' 1facfD��ot� Alil..��,..z.. MENONM DFSCRIPTION OF WORK TO BE PREFORMED: OWNER: Name: Please Type or Print Clearly) ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON .00 PER S.F. 457iop"LTotal Project Cost: $FEE: $ Check No.: L Ile Receipt No.: ap NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISP0 Public Sewer 7 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 DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED CONSERVATION 7 7 COMMENTS ��} DATE REJECTED HEALTH COMMENTS v DATE APPROVED El Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: 4 - Comments Comments Wate.r., ,,Sewer Connection/Signature &Date Drivewav Permit Lcy�aied at i8F4 Osgood Street 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 Doc.Building Permit Revised 2007 I7, 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 /Bui9 PP ildin Permit Application . ❑ Certified Surveyed Plot Plan g/Workerst-omp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses opy Of Contract door/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Energy Compliance Report (If Applicable) -a n ring 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 Li 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 2.2007 Location Z0 -- No. Date =ram— NORTH TOWN OF NORTH ANDOVER OL Certificate of Occupancy $ •'Ss�cNusEtA Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 6 2 1868 �\ Building Inspector '\.l"``3:-'�=f'"`�-.c3,--�'ln•,,..._.,n,<�-+,..t-�aJ,r....f.'v'"�`�1,-,^++,�''�.*=�,,ti,��,.,�e,.yr....-« �v ,�,�,.�;,...-,:,�--Y�� -•:vv-i,�q'"'^r',,-��L-•-�--h3j�.:t,.,.u�1Gv'>i"�" ��''+'"�" W% -- - -- - 4 rropvsai TwomEY & LEGARE CONTRACTING Professional Building / Remodeling P.O. Box 366 Shaun Twomey No. Andover, MA 01845 Doug Legare 978-685-7447 978-556-1547 NAME OF OWNER - Ca,,� 141, A91') �✓%Cl/ ADDRESS OF JOB "� � J� �/L/U)GI' �C.�'' ��t.' ./ �%�� /�''"" -e- TEL. DATE: We hereby submit estimates for: '4� - Ao,— �G��r �er�% � a'' .tea �•� %� We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: a� ,,,�► dollars ($ ). Payment to be made as follows: /,4r� J/�Q��'✓1GRJ �• Authorized Signature NOTE:This proposal may be �y withdrawn by us if not accepted within 10 days. Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payment will be made as outlined above. Signature �r C Date of Acceptance: Signature . Zz✓ e IA 1614 Lf, A .ire-` .LLIio/4VUU 0;Ud;JZ) AM ?Aur- �J/Uu;9 rax aerver e w ACORDr CERTIFICATE OF INSURANCE DATE(MM`DD\YY) 12.16-08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE DOHERTY INS AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ELM STREET, ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PIS BOX 1485 COMPANIES AFFORDING COVERAGE AN'DOVE'R., MA UISIU COMPANY A TT2AVELERS INDEMNffY COSIPAVT INSURED COMPANY B !,k:GAitEi(_0\'1'RA(')'IV6 L\'C COMPANY PO BOX 3156 C `'ORTH .ANDOVER. MA 01845 COMPANY D COVERAGE fHIS tS TO CEPTIPY THAT THE POL,CIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INS UPEO NAMED ABOVE FOR THE POLICY PERIOD INDICATED, M7TW THS) "DING ANYREOWREMENI, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR reAY FEP.TAII. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. -;NITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE (MMrDD,Y`) DATE LIMITS GENERAL LIABILITY GF.NEF.ALAGGREGATE. b C0b1MERCLAI.(71EN=PAL ?ROCUCTS-COM01OP AOG. b CLA M5 MADE CCCUR PERSONAL 1& ADV. INJURY :)WNER'S && CONTRACTOR'S PROT. EACH OCCURRENCE 3 FIRE DAMAGE IAnv cne tit*: $ MED. EXPENSE ;Any one F4rson) AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT b ALL:AVNEC AU' -_S BODILY INJURY (Per Perscn) b SCHEDULE AUTOS BODILY INJURY (Per AcciciRnf b -BRED AUTOS PROPERTY CAMAGE $ 1,'O14-CWNEC 4U7CS GARAGE LIABILITY ANY AUTOS AUTO ONLY - EA ACCIDENT b OTHER THAN AUTC ON. -Y: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY .�M?RE_LA,ORNI ;AC,,CCCURFENCE $ OTHER THAN UMERE-LLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'SLIABiLITY UB -02901101994-08 OS -18-08 09-18-09 STATUTORY'-IMITS C TtiE PROPRIETOR EACH ACCIDENT $ 500.000 'ARTNERS:EXE','UTIV= INCL DISEASE • POLICY LIMIT $ 500,000 OFFICERS ARE. X EX';L DISEASE • EACH EMPLOYEE $ 500,000 OTHER DESCRIPTION OF OPERATIONS;LOCA T IONS/VEHICLES,RESTRICTIONSISPECIAL ITEMS 'I-Y.:SFEYLACP.SANA PRICK C'.EXIIF:CA VIE ISSUED '1'0': HL'UL,11FICA'I'E HOLDER AEFECIINGWiKF -LKSCONAYCOVERAOC CERTIFICATE HOLDER i'(-1 WN OI-' :NORTH A.ND(W ER I('),r? OS(-'YOOD STREET NORTH ANLK)VER.:NIA 0:,;45 ACORD 2S-5 (3193) CANCELLATION SHCiULU ANY Jf: THS ABOVE DESCRIBEE "✓LIC'ES BE C4NCELLED BEFORE THE EXP-RATK)N C•ATE THEREO", THE IESUENGCOPAPANY HILL ENDEAVOR f0 VAIN 10 DAYS WRITTEN IJCTICE 70 THE CERTIFICATE HO' -DEF NAMED TO THE LEFT. BUT FAILURE 1'0 VAIL SUCH NOT'CE SHALL WPO:E NO -DELIGATION OR LIABILITY O° ANY KIND JPUN THE COFAPANI'. 1T9 AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Chirles 1 Clark V --- , , C ACORDr� CERTIFICATE OF LIABILITY INSURANCE DAT20081DIYYYY) 06/25/2008 10:29 PRODUCER (800) 225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Fred C. Church. Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 40 Kenoza Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I laverhill. MA 01830 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 300-225-1865 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Arbella Protection Insurance Company — MED EXP (Any one person) INSURER B: — --- --- --- --- -------- 1\\omcc 8 Leeare Contracline Inc P 0, Bos 366 Norlh Andover. MA 01845 ----- INSURER C: ---_-------------_ _ __ -".-- I INSURER D: S 1.000.000.00 INSURER E: `--I 8500012700 V V V C rV1 V GJ 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 CONDITIONV OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. w5R gDD'l; L TRTYPE OF INSU POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION i LIMITS IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR GENERAL LIABILITY j X ! COMMERCIAL GENERAL LIABILITY REPRESENTATIVES. AUTHORIZED REPRESENTATIVE IPREMISES EACH OCCURRENCE S 1,000,0OO.OU [DAMAGEO RENTED Ea occurence 100,000.00 _ S __-___ MED EXP (Any one person) S 5.000.00 i ''• I7 CLAIMS MADE OCCUR I PERSOr NAL t1 ADV IN_A Rv S 1.000.000.00 `--I 8500012700 6/22/2008 I 6/22/2009 I— I ._--.--..--------------- GEN'L AGGREGATE LIMIT APPLIES PER: r PRO- POLICY I jrcT�— I LOC i I 1 � LGENERALAGGREGATE PRODUCTS -COMP/OP AGG COMM $ 2.000.000.00 ---- --- -- S 2.000.000.00 AUTOMOBILE LIABILITY HANY AUTO I COMBINED SINGLE LIMIT (Eaaccident) S ALL OWNED AUTOS �--- SCHEDULED AUTOS r-- I i BODILY INJURY (Per person) Is i—� HIRED AUTOS I ! NON -OWNED AUTOS—__ I I I BODILY INJURY (Per accident) S --.--.-- PROPERTY DAMAGE (Per accident) S I f ---I ------------------ I i I + I GARAGE LIABILITYi AUTO ONLY - EA ACCIDENT I S OTHER THAN EA ACC AUTO ONLY: AGG - ' ANY AUTO 1I5 — 1 5 EXCESS/UMBRELLALIABILITY i EACH OCCURRENCE S I AGGREGATE S l !OCCUR CLAIMS MADE 5 _J —� DEDUCTIBLE i S RETENTION S I WORKERS COMPENSATION AND WC STATU- OTH- TORY LIMITS _E-R�' I EMPLOYERS' UABILITY ANv PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED I I E.L. EACH ACCIDENT 15 E.L. DISEASE - EA EMPLOYEE "--'-- S If yes, descntx under I SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT I S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS GI. Ccn CERTIFICATE HOLDER CANCELLATION Town of -North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 27 Charles Street DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN North Andover. MA O 1 845 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) Client # 5458 MSt # 08/09 Cert a © ACORD CORPORATION 1988 rpm0� e..." G ads . -\ Board of Building Regulati ns and Standard's HOME IMPROVEMENT CONTRACTOR Regist tiOR* 136779 1. on;-- =P Tr# 272934 '4n -ershriership I f TWOMEY+ LE Or'`1. G INC. M SHAWN TWO 61 PATRIOT ST: N. ANDOVER, MA 0184 Administrator 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print Lesibly Name (Business/organization/individual): Address: City/State/Zip:./ L ��v li�� � Phone M:—A4-S— :__ A4 -S-0 41 i Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the subcontractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling ship and have no employees ese subcontractors have 8. [] Demolition working for me in any capacity. Zarkers 9 comp, insurance. 9. ❑ Building addition [No workers' comp, insurance 5• 1VWe are a corporation and its required] officers have exercised their 10.❑ 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.❑ Bobf repairs insurance required.] t employees. [No workers' MU Other_ comp. insurance required.] , as -i '••�.•,a n.,� ... — mau ins wu u1c 3 non oaow snowing tmar workers' compensation potion information. ' t Homeowners who submit this affidavit indicating they ate 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•conbWtors and their workers' co policy infomation _ mp• po c3' [am an employer that is providing workers' compensation insurance for my employees information. Below is the policy and job site Insurance Company Name: // e Policy # or Self -ins. Lic. # 1/07 / Expiration Date: Job Site AddressXZ(/`�Udr%o� 1,c., �00/ 4j�,,G./ 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ua��pai� d penalties of perjury 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 offleiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone M 7777 Wit'. 4 A. u► a l/y 14� " �1. � xk a a ah �..I 1.. _ to to w cY w w U w" c4 w a �'i w C2 w t a co % co CL ca MCC Yw 0 2 4D CA 0 CL Cp e Q fij 00o U 'FE mm . r 0 7 N o co cm ul 13- 3� O y • ^� cm yi = i2oft CL.) w O , OP c �+ •'o F� (n (•� C� i. per` dM: — •� m O O •� _ 4.4 evca o W O y C Cq 4D 4>D co = a W c F m V y w :� � � c� •� Z o O C p. .r'coo c O ca o a u H o m n w c N C Z ", LL�H orvwc � y F- y •=_ - Z m .E � """ o •y p G a` v v� `mca a -0 U ca 4D C" o.c c m•Dim O� o N •� O { _ D Q 0o W. o dU") U J M m 12- 0--l' 0v O Q