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HomeMy WebLinkAboutBuilding Permit #325-14 - 354 MAIN STREET 10/4/2013 TOWN OF NORTH ANDOVER � j APPLICATION FOR PLAN EXAMINATION Permit NO:� " � Date Received Date Issued: -6 4 I ORTANT:Applicant must complete all items on this page LOCATION 3,,5,q M '4 s {' Jj Print PROPERTY OWNER�o k A Ph f l a n Print MAP NO:o4PARCEL:W}7 CLONING DISTRICT: Historic District yes &no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑ Iteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ® S ptic, 0'1W 11 ®Flo dp'1 ® W�e Ian"�ds� �Di 7afer�;shed Distrix �❑WateX�S�we% ' DESCRIPTION OF WORIK,TO BE PERiiO' -D: (Identification Please Type or Print Clearly) OWNER: Name: v Ph-t Phone:ctZ Address: CONTRACTOR Name: cr V r-ek Phone:9 Z W 33 Address: 10 ju ; // sf. N. 2eao ��y ® tS6�f Supervisor's Construction License: _(Q g-q/ 3 Exp. Date: Home Improvement License: J23r5Z Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ "l 5-0 FEE: $_ 1 4 11L Check No.: Receipt No.: W�! NOTE: Persons contracting 'th unregistered contractors do not have access to the guaranty fund Signature'ofjAgentlO�wner ._. .- _._ Signature_of,contractor �i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools El 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 Siqnature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board'Decision: Comments � I 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 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. it.: 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 2008mi I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. f 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 o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products DOTE: 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 Pian 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 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: Doc.Building Permit Revised 2008mi Location No. Date 1� • - TOWN OF NORTH ANDOVER ® Certificate of Occupancy $ Building/Frame Permit Fee $—%,-60 Foundation Permit Fee $ : tK ^` Other Permit Fee $ �f' r Nva' TOTAL $ Check# tlY�/ 26960 /Building Inspector � NORTy Town of t EAndover No. 39..iq 4 h ver, Mass 6bee q 201 -32 toc.nt ne wec� �1' L) BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System (n' 0 THIS CERTIFIES THAT ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR .......................� ... C.. has permission to erect buildings on Foundation Rough 4:....a... ...........tt to be occupied as .............. ... .... ......... 0 . ..................................................................... Chimney provided that the person accepting this permit shall in every 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI STARTS Rough - Service ` ........ ..... .................. ...:..................................... 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 1V Ei O . Roofing 9 Gutters COLLECTIO CONSTRUCTION CertainTeed C-1 P. O. Box 156 North Reading, MA 01864 (978)664-5633 Fully Insured Lic. #68413 Reg. #123852 PROPOSAL SUBMTITED TO / / PHONE DATE- STREET t. JOB NAME 4 I CTiY STATE ZIP JOB LOCATION We hereby submit specifications and estimates for: it ( rl� � � rl r• r � .�t. t i � { S y,/r? l/1 f 1 4. _ �1.,7 P�F.� fir,er F. 7 J /r r—�, %r ( � / ! �/..s. t. � r � fig{A � c.� ,y�„ ., T< / � n '�,. J, 17 1• f'i 1 r t u `i �r:t.,( (c �, t r r i I u,�i f �r Vi F'�' e'J /7 V J r ' r ` �" r �4�e , A f f, z SI It v �v<a} }'C-1 '44, �0off G4/ to L3 ,, 1 Gt 3 'r C 00% ' S 0 Cl �'7 000 CIO, Skz o/J4 Price includes removal of all job related debris. 3 R�� ,-J P 'Please note:All items in attic should be covered during roof tear-off. We Propose hereby to furnish material and labor--complete in accordance with above specifications,for the sum of: ttl(I-aI���WCIc- dollars ($ Payment to be made as follows: 1. 1' n 4/I�`t^ Ll! `I i�;� J�l �11 j• � � 3` '�t I �.."' r` Note: This proposal may be withdrawn by us if not accepted within days. Acceptance of Proposal: The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to f �, do work as specified. Payment will be made as outlined above. f Signature Signature lck'►1n Note: Unpaid bills over 30 days subject to 1-1/2%finance charge per month(18%annual). I 7/24/2013 10:31 AM FROM: Fax M.J. Foster Insurance Services, Inc. TO: 19786645633 PAGE: 002 OF 002 ,4co o® CERTIFICATE OF LIABILITY INSURANCE OAT 07/24/2013 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 pollcy(les) 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 CONTACT NAME: NORTH ANDOVER INSURANCE AGENCY, INC. p Nd, En: (978) 686-2266 A 2, No)' (978) 686-6910 M.J. FOSTER INSURANCE SERVICES AODR1Ess: 163 MAIN STREET PRODUCER CUSTOMER D Y: NORTH ANDOVER MA 01845-2508 INSURER(S)AFFORDING COVERAGE NAIC s INSURED INSURER A :TRAVELERS INSURANCE CO. DANIEL OLIVEIRA, JR. INSURERS MERCHANTS INSURANCE GROUP —— OLIVEIRA CONSTRUCTION INSURER C :HARTFORD INSURANCE P.O. BOX 156 INSURER D INSURER E NORTH READING MA 01864- 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. NSR B LTR TYPE OF INSURANCE NSR MND POLICY NUMBER POLICY EFF POUCY Exp (MwDO/YYYY) (MWDDNYYY) LIMITS A GENERAL LIABILITY Y 5809121202902 6/01/2013 6/01/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea otcRbnce $ 300,000 CLAIMS-MADE FX-1 OCCUR / / / / MED EXP(Any one person) $ 5,000 PERSONAL d ALDV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER / / / / PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY 7PROT JECLOC / / / / $ B AUTOMOBILE LU\BLRY MCA7015598 0/25/2012 0/25/2013 COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ / / / / X SCHEDULED AUTOS / / / / BODILY INJURY(Per accident) $ PROPERTY DAMAGE X HIRED.4UTOS / / / / (Per accident) $ X NON-OV'.NED AUTOS / / / / $ X COLL d COMP DEDUCTIBLES / / / / COLL 8 COMP-$500 DED'S $ SOO OCCUR LILU �—I EACH OCCURRENCE $ ExMB ceREss Lue LAS CLAIMS-MADE / / / / AGGREGATE $ DEDUCTIBLE $ RETENTION $ / / / / $ C WORKERS COMPENSATION 66OUB-SB50092-6-13 7/23/2013 7/23/2014 VAC STATU- OTH- AND EMPLOYERS' LIABILITY X R II ER ANY PROPRIE TORRARTNER/EXECUTIVE YIN OFEICE2m EMBER EXCLUDED? NIA E L EACH ACCIDENT $ 1 OOO,000 ❑ (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1 0001000 lyes OesCnDe Under DESCRIPTION OF OPERATIONS Delow / / / / E L DISEASE-POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, AddUonal Remarks SChodde, It more space IS Iequlrad) EVIDENCE ; CERTIFICATE HOLDER CANCELLATION 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 ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD `'` The Commonwealth o Massachusetts f Department of Industrial Accidents Office of Investigations I ' � 6 : 00 Washington Street Boston, MA 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business!Organization/Individual);�/­ i UQ�/4 Cd�►STiVG7�wI Address:p,c) tom 15(, City/Slate/Zip: /),P.e`d,'g ti Q B'G Phone #: GOt-1-6631 Are you an employer? Check the appropriate box: Type of project (required). 1.91 am a employer with 4. ❑ 1 am a general contractor and 1 employees (full and/or part-time).' have hired the sub-contractors 6. El New construction �.❑ 1 am a sole proprietor or partner- listed on the altached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' INo workers' comp. insurance comp. insurance.* 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or addition.~ officers have exercised their 3.❑ 1 am a homeowner doing all work l l.❑ Plumbing repairs or additions myself. [Nto workers' comp. right of exemption per MGL 12.gRoof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 131-1 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a ne,, a(f ldarit mdicaune•u.h :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether of not those entities ha,( 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 isthe police and job site information. Insurance Company Name: i4Aky-el T-4 /¢�eaG� 9 Policy #or Self'-ins. Lic. #: 656000 lag,0 a01 L Expiration Date: 7'Z3�` E Job Site Address: it /llor-� /� �I'/ /�w%n S C �'/Slate/Zip. � /-6`24 ,Pi At. 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 it 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 it f int 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 under the pains and penalties of perjury that the information provided above is true and correct. v Signature: s t Dale f d'- Phone N:�-7 l9lD q 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 6. Other Contact Person: Phone#: I ��e�par��r�aan2uecr,LG�o���czaaac�uaeC��. Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration: 123852 Type: ± i xpiration:. 4/1572015 DBA — �t . Oliveira Construction Daniel Oliveira,Jr 10 Mill street g Boz N.Reading,MA 01864 Undersecretary I • Massachusetts -Department of Public.Saf6ty Board of Building Regulations and Standards Construction Supen isor License: CS-068413 DANIEL OLIVEIRX JR w 10 MILL ST N READING MA-01864 { r it W'` Expiration. Commissioner 06/2W2014 c II I