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Home My WebLink AboutBuilding Permit #416-2016 - 361 MARBLERIDGE ROAD 10/2/2015 OF N°RTFf '9 BUILDING PERMIT t6eD TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION '` Pan it NO: ' Date ReceivedAMED ++ �' Date Issued: t 7/ �9sSacHs IMPORTANT:Applicant must complete all items on this p#&e LOCATION jAArlole_ t \ Ffrint PROPERTY OWNER �J Mint MAP NO: bJPARCEL: ZONING DISTRICT: Historic District yesnno Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential 10 New Building ❑ One family n Addition 0 Two or more family ❑ Industrial N.Alteration No. of units: 0 Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other ❑ Septic Q,Well ElFloodplain ❑Wetlands [IWatershed District ❑Water/Sewer 1A !�Wl 71U71rt ZkU-k i �AA&AAux� AA_ Art-e— V 1tA_ _As- `J Identification Please Type or Print Clearly) (DMER: Name: Pail Phone: 331 Address: CONTRACTOR Name: Phone: 60�3 156t all a�rcr�1�. e �Lural�r Address: J-10 16-4- Supervisor's Construction license; Exp. Date: 0qtf?v3 Home Improvement License: Exp. Date: n p q ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED C ST.BASED ON$125.00 Pte?SF: Total -6 Project Cost: $ L �< FEE: $ q__ _ _ Check No.: 217 Receipt No.: 2-9gSl NOTE: Persons contrac ` g with unr co dors do not have access o he guar fi ._ Signature of Agent/Owner Signature of contractor �+o M L r BUILDING PERMIT QNORTF1 w- lS ��t LED ,b qw-O TOWN OF NORTH ANDOVER2 APPLICATION FOR PLAN EXAMINATION h O www • 7� '� Permit No#: Date Received y 0 A7ED SSAC HU Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION - -- _Pr int Print PROPERTY OWNER _ ___ _-_- - _.. _ __ Print 400 Year stfudure yes. no MAP --,PARCEL: _-_ , ___ ZONING Dl$TRI:CT:`Historic District yes: no Machine Shop Village yes, not 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 ❑ Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District ❑Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: f Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: _ - __ �__ a - _Phone: _- _ Email: Address: Supervisor's Construction License: __ Exp. Date:_m Home Improvement License: __ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Personsv contracting with unregistered contractors do not have a(cess to the guaranty fund rSig.nafure of Agent/Owner - Signature of contractor - -- - - 7 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/Cross Section/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 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 j Doc:Building Permit Revised 2014 A , Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ 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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature r 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: Signature: — — � -�— _ _ _ _ _ 384 Osgood Located Street �FIRE;fiDEPARaTMENT TempiDumpster{onrslte ,yes ono . t ¢Locatedat r124'MairrrSfeet" "`� ;Fire.'Departr,nj s_ gnatur�ldate_.� _ ,tCOMMENTS�_ L 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.$10o-$1000 fine I NOTES and DATA— (For department use) } i i ❑ Notified for pickup Call Email Date Time Contact Name = Doc.Building Permit Revised 2014 Location 2A"1 No. `! !tP ' Date • TOWN OF NORTH ANDOVER ; Certificate of Occupancy $ Building/Frame Permit Fee $ a_ - } Foundation Permit Fee $ Other Permit Fee $ ITM TOTAL $ Check# 29451 Building Inspector NORTH Town of E I� Andover o � o h , ver, Mass, �1A COC NICIO WICK 7.0 ORATED s BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT 4...... 4BUILDING INSPECTOR //�� Foundation f has permission to erect buildings on �.... !7�. ..... ................�.... .......................... Rough '` ('e. to be occupied as ....�L.A.M... l!��.1/. ....."f . . .!+�St............................. 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 MONTFJ§ ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TS Rough 1 Service ............... ......DN.. ........................................ 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. Mass Construction Supervisor LIC#094703 r!� Mass HIC License#265732 CkStOK& Carpe.Kb of New EV1.0Lavol Making Your Drum Home A Reality �. Owner Donnie Settlemoir < 90 Lakeshore Dr Georgetown Ma Office (978)769-2114 Cell (603)601-2114 Fax (603) 501-0124 ,, www.customcarpentryofnewengland.com Don nee@comcast.net f +� Name Address A/1/4A -- Town /I,/- yJ0,,*-- Stated Zipy� ? Phone �� v- ':ZS-+3 Emr vail r ��ral � z..,,,,,d � V So— Referred bytion of C4Descri Service A A f ek'-4- (610 o Quotation prepared by: Donnie Settlemoir Total Cost 3� Payment schedule goes as followed. Half of the construction cost at the beginning of project $ The final payment at the end of project. $ 0� CPO To accept this quotation, sign here and return: _ Y The Commonwealth of Massa.chusefis Department of IndustrialAccidents - „ - 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip:6fGrp fg)a k / 0, Phone#: e56`3 Are you an employer?Check the appropriate box: n Type of project()required): l,A4—am a employer with employees(full and/or part-time).* 7. E]New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 3..❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. F1 Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor andI have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.T 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other �A p S' 152,§1(4),and we have nq employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t homeowners who submit Ns affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 employ ees,'they must provide their workers'comp.policy number. lam 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.Lie.#: l 6 t1 j�— ^) Expiration Date: Job Site Address: b ✓vl(s!41City/State/Zip: IJ- J�j4d&yey - Attach a copy of the workers'compensation policy dec aration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif der the pains apenal ies ofpeijuiy that the information provided above is true and correct. Signature: r� Date: 10 � a Phone#: �� Cy 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 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'66hire, 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-outthe 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 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 foi•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 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 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 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 permit 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-DAASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia A� �® DATE C� CTS �� `.... LIABILITY INSURANCE 07116ra THIS CERTIFICATE 15 ISSUED ASA T11�I MON ONLY AND CONFERS NO RIGH THE CERTIFICATE HOLDER CERTIFICATE-DOES NOT AFFIRMAIMY OR 3AVELY AMEND. EXTEND OR ALTER THE 14ELOW. THIS CERTIFICATE OF INSURANCE DOES norCONSTITUTE A CONTRACT BETWEEFJ THIS AFFORDED BY THE REPRESENTATIVE OR PRODUCER,AND THE TE HOLDER. INSURER(S), AUTHONZED IMPORTANT- If the certifittmte holder Is a INSURED,the pol)cq(tes)must be enaorselL R TION IS WANED, the terms and cond`itlom of the policy, sutip � cmtfficata holder ht ftu of such endbrsemerrt(e �an endorsement A statement on t!t$S cote does not confer rights 1hD thm Didi iF Insurance 978-W-2533 F Main Street E `suffeelow VA AFFOR0016 COVENAt;E A.TTavelms Donnie SeIF_ r dba tea-AtlanticCasua{ilr Ins Co Custom Cmi;;tTy Of New England I c: 90 take Shore Drive 913111HERID., ' Georgetown »F: MA 01833 BOUFMF, COVERAGES CERTIFICATE NUMBER: T ►S`f0 CERTIFY THAT THE POLICIES OF INSURANCE LtS#ED SIC IU,1lE BEEN SUED T9 THE S13t>IiEO N/ISIO NUMBER: NE=TED. NOTW[T?6jANI ANY REQUIREMENT,TERM OR COIoI1>N OF Ai[1'CONTRACT OTHER ABOVE FOR THE POLICY pEraM CATE MAY BE OR MAY PERTAIN,THE BY POtfC S DDCt1i�Mi WITH RESPECT TO Wi9CH T EI ONS AND CONDIrIf=OF SUCH POLICIES.LMS UAY HAVE BEEN REDUCED PO CI PAID CIAO H�IS SUBJECT TO ALL THE r TYPEOFRISCIRANCE WRIN PCX= PMO�D EFF P EXP . COMMERCIAL 68 ERAL LTAB LTTY LIMITS CLAWS Q OCCUR E $ 1,000.0w - Puesasea $ 100,000 L7 VIED EXP orre Person $ 5,000' 12/17!2014 12/17P�15 PENIAL&ADVLMIURy $ 1,000,OOtD fEIV'L AGGREGSATE LIMIT APPLIES PER YJ Re LOC LEGATE $ 2,000" OTHER: PRODl1GT8-COMPIOPAGO $ 2,000,000 AIrTOMpBILE LIABILnY $ ANY AUTO LIM $ ALu OcWNED SCHEDULED Y RUURY(Per person) $ AUTOS HIREDAUTOS NON-0WNEO Y@OR1RY(Aer $ AUTOS 41,010 UMaRELLAUAR OCRAtEXCESS LIAR SDE EACH OCCU� RETENTIONS A WCOMPENSAYMMMEMPLOYERS'LIABR Y1N ►�A PROPRIET,, RTNEIyE)M� EREMBER EXCLUDED? a NIA f-15 EL.�lACCIDENT ry in NH) 07/15/2015 07115/2 6 describe underF-L-D -EA EMPL PTION OF OPERATIONS belanerrequkee E1-DISEASE-POLICY LIMIT $ 500. DESCRIPTION OF OI'FRATLONS!LOCATIONS I VEHICLES( �A Remarks SehedoM,may 6e attached H mom spaett ra cATE HOLDER CAIdtLLATION �! SHOULD ANY OF THE ABOVE DES C>i XF THE EXPIRATION DATE ��8E CAN BETHEREOF, IanCE tNILL BE a ACCORDANCE WITH THE POLICY PRoMMONS. AUTHORIZED REP A dill langeil MMM 25(2014101) The ACOi�42 Wgo are 2014 ACO RPORATION. All rights registered marks of ACORD a Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 , Home Improvement Co�- `ntractor Registration Registration: 159042 f7) Type: DBA '� is Expiration: 3/28/2016 Tr# 249423 CUSTOM CARPENTRY OF NEW ENGLAND? DONNIE SETTLEMOIR --- 90 LAKE SHORE DR. GEORGETOWN, MA 01833 Update Address and return card.Mark reason for change- SCA 1 0 2OM-WI I Address 0 Renewal [] Employment F] Lost Card Office of✓Consumer Affairs&Business Regulation License or registration valid for individal use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistrafion: :159042 Type: Office of Consumer Affairs and Business Regulation xpiration:—3128/..2006g DBA 10 Park Plaza-Suite 5170 f�i rt, Boston,M 16 CUSTOM CARPENTRY OFNEWINGLAND i'�My DONNIE SETTLEMOIR ,`.., 90 LAKE SHORE DR. sF ,$ GEORGETOWN,MA 0163 – Undersecretary Not valid without signature Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: C&M703 DONNIE SETTLEAOIR - 90 LAKE SHOR�?R') GEORGETOWN:iV 61833 Expiration commissioner 10/312015