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HomeMy WebLinkAboutBuilding Permit #487-2011 - 350 HOLT ROAD 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ),o / Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 3 SV Print PROPERTY OWNER S''�E 41 P /-► to,,, --C,-&L _ Print MAP NO: PARCEL: O/ ZONING DISTRICT: Historic District yes no Machine Shop Village yes 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 r®TSeptic' ®Well�� � w # OEloodplan `Wetlands+ �s + `®Waters d1D strict% 1 i�.�Water/Sewerw ..___ _ ..,. ._sk_._� �--.,_...-_-= - - - - - - - -•!` - - - c� DESCRIPTION OF WORK T BE PERFORMED: F,2sl V�j-4-+,L N G >r Fl)e ?`ll'L 2 r- %s T d'^_y A r S. Identification Please Type or Print Clearl OWNER: Name: C V s �'0 '/t PA PC, JL- G. Phone: CI7 Z2Yr 196-10 Address: 3 �� �'�U LT 1?=a 4 Q. �J 0021 CONTRACTOR Name: L C+G7'11- Phone: b l 7 31 14d' Gu Address: 11-�i V<-/l A-1c,n/ _-- CA/✓I-✓--C-���Wl. /VI ^ A- Supervisor's Construction License: Exp. Date: V Z Z U •Z Home Improvement License: l V �� U Exp. Date: 7 - 2 - 2y 1 Z ARCHITECT/ENGINEER T M L cJ N1� Phone: 0 " Address:L 6L F o n.£S 7- s 7'2X-c T Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ y FEE: $ 6�a Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access t he guaranty fund t - --- - :_ - Si natuie ofTA entWwne Sigriafure of,contractor _ _. , 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) ❑ 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 VOTE: 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 hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording oust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi 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 Notified for pickup - Date Doc:.Building Permit Revised 2008 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 Si nature g COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes l . 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 Main Street Fire Department signature/date COMMENTS Location _ 3S d I-1 10 174 Al No. y�7- ?o// Date NORTA, TOWN OF NORTH ANDOVER 0 •. , OR Certificate of Occupancy $ N�s t� Building/Frame Permit Fee $ 40 C) Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # i 237 / 3 Budding Inspector ORTH Tovm of Andover No.- o �� ~ P.... LAKE -O dover, Mass., /z zl�� Llll COCKICKEWICK ADRATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR �...../...�.C../...s........C.�...E...f....... „ ....,,,,,.(/.. `.,O,THIS CERTIFIES THAT............... E� o ................. ..................... .. .... .......................... Foundation has permission to erect........................................ buildings on .131:51' A .............................. ......................... Rough to be occupied as 1?.6 ` .. .,....... Chimney Al,�� ............................................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 PERMEXPIRES IN 6 MONTHS Final IT ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough ........04A..... f"�/-'�"" .,.,....................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wail To Be Done E FIRE DEPARTMENT Burner Until Inspected and Approved by the Building Inspector. . Street No. SEE itEV E RS E SIDE Smoke Det. Massachusetts- Department of Public Safety Board of Building; Re�ulations and Standards Construction Supervisor License License: CS 51359 ` I GARRY M BALBONI "*' 129 VERNON ST «' WAKEFIELD, MA 01880 Expiration: 10/28/2012 Commissioner Tr#: 7298 ✓lie �o>:niazorauea/��o ✓f/�a'asacfu�aelta- office of Consumer Affairs&B smess Regulation HOME IMPROVEMENT CONTRACTOR w Registration:,11 P5790 Type: ; Expiration: =7%21/20_12 Partnership AL RTA&BALB�NICONST(NC)? GARRY BALBONh; 120 VERNON ST WAKEFIELD, MA 01880HUndersecretary Fax Server 12/15/2010 3 : 07 : 21 PM PAGE 2/002 Fax Server F__DATEMMIDDIYYYY)) ACORO° CERTIFICATE OF LIABILITY INSURANCE 1211512010 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. Astatement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER Phone: (781)933-3100 Fax (781)933-9048 CONTACT Karen Makso NAM E SALEM FIVE BOYLE INSURANCE SERVICES,LLC PHONE 7811 933-3100 PA" (781)933-9048 AfC No Ext: ( ! A/C,N 445 MAIN ST E-MAIL karen.makso@salemfive.com WOBURN MA 01801 ADDRESS: PRODUCER 23509 CUSTOMER ID INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER Continental Western Insurance Co 31325 ALBERTA&BALBONI CONSTRUCTION CITATION INS CO 40274 CIO MICHAEL ALBERTA&GARRY BALBONI INSURER 8 17 CHEEVER STREET INSURER C SAUGUS MA 01906 INSURERD: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 41783 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 TYPE OF INSURANCE ADDL SUBR PODCY EFF POUCYEXP LTR INSR wvD POLICY NUMBER MMroDfYY" IMM1DD1YYYY1 LIMITS A GENERAL LIABILITY BOA0333124-10 03114110 03/20111 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 PREMISES Ea ocaF_ CLAIMS-MADE I-XI OCCUR MED.EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-CCMP/OP AGG $ POLICY PRO- E] RO OC B AUTOMOBILE LIABILITY BCYLBD 06126/10 06/26111 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE HIREDAUTOS (Peraccident) $ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ Exc ESS LIAR HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION WCA033331710 03120/10 03/20111 X WC STATU- X OTH $ AND EMPLOYERS' LIABILITY TORY LIMITS YIN ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFx:ERIMEMBER E.(CLUDEDI NIA (MaMatoyin NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 II yes,describe under DESCRIPTION OF OPERATIONS belay E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 Osgood St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: Bldg Dept &en Gerard oyle Jr, r ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts 1 1 Department of Industrial Accidents �y l Office of Investigations , 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information DD Please Print'Legibly Name (Business/Organization/Individual): �/.�— Lnr!'A I��} /yl-N,,1 GO e-4(2- Address: C 1+Cr—t,c 2 /�- City/State/Zip: ;,5"11V4-10'5 U /Phone#: 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[j411 am a sole proprietor or partner- listed on the attached sheet. # 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition [No workers' comp,insurance 5. ❑ We 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 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.F1 Roof repairs insurance required.] employees.[No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#I 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 acid 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: h Policy#or Self-ins.Lic.#: 1tJAr 3 3 7 I Expiration Date: 3— 2 V - Zy 1 J Job Site Address: 3 Sy RW LT M ID 1V&&rJ' •A L,0 W#'C�ty/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 cert fynder the pains andpenalties ofpeijury that the information provided above is true and correct' Si nature: Date: Z "" �s� ZU C7 Phone#: Official use only. Do not write in this area,to be completer)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#: Information and Instructions 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 of hire, 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 1-52, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or ren6w2d 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 numbers)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 cavy workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be 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 pen-nit 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 is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event'the Office of Investigation's has to contact you regarding the applicant. Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition,an applicant that must submit multiple-pennit/license`applications'in.any given year,need'only submit 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. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen-nit not related to any business or commercial venture (i.e. a dog license or permit 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 Commonwealth,of Massachusetts, Department of Industriaf Accidents Office of Investigations 600 Washington Street - Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia LLI PARTITIONS, PER ADA REQ. __ _y \ I + y ee,,,, OL lL 0 O 0 TIL. I 1 --7--t--1 Lu If I If- rJ1 W 4Ei–� �1 LT- 4-- 7_1 (� /♦� N L� I--i-1 4- co _ I I I_ y BATHROOM WALL � _d � , t L �i I - E 1 I- � u l _ II U AZ.1 SCAV4•■1'4P �_i +---� I � � j 1 I til q LE Z EXISTNG BATHROOM PL 4N �ERED ARC Q A2.1 8C"V4•■r-W �t�, p�11Y E.4 n 11 N ss. J OF -T 1_ ,_! ' 1��.:_.' I ;._-�I:_I__ � �1 �.+ '–I � , i� ; i – } 17ol r � _ _�- - --T-1.1I Y"-f_1. I j�r. I I �cvl BATf"'!I�/L1 7 MILL ,-j �c TBATF IT + 1 i AZ.1 SCALE+IR4"■I-O' L_ rI _ Ll -� I_– �– _7 rte- f– ACCESS1 BLE MIRROR 5c� 8' d GRAB BARS r– I -* PROVIDE COVER TO �_I_ - _ Ln EXPOSED PIPES, AS —+ }1. ; PER ADA REQUIREMENTS �' - rt- Y , I L -.� I I I i l 1 f h r _ Ln LLt rt r w N O 4 ! Bi i- i - -r + �1} 1 7 }-I �(� F F' 2'_�✓u 21_5u 3i_0u 3_611 _6u 'QE �F-(–� ' �I - r --�–r } (� y! V• i_.�-� ' -1-I-1 _I--- -+--I--r '�,� Q •� •� Q ' I— !-� +�. r, PROPOSED BATHROOM PLAN O O p tt tt 4 BATHROOM WALL 3 BATHROOM WALL A2J ecAL�v4■•1'-m' lu , 2J aCALE.I/4•■1'-O• AZ SCALE.1/4•.1'-O' P A W � 1— c��, Z .r. � Copyright,Timothy E.Lund,Archlt=t