HomeMy WebLinkAboutBuilding Permit #621-2017 - 373 RALEIGH TAVERN LANE 5/1/2018 ' r`. 41 f/}y - f NORTFr q BUILDING PERMIT ..6 0 3 L TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINAT50N - 11 i s Permit NO: I Date Received DAAieD '�`` Date Issued: �ssgcaus�t IMPORTANT:Applicant must complete all items on this Eae LOCATION -3-7 �-^ Prigt PROPERTY OWNER /Qoo F'r'�l1VGl/►1t Print MAP NO: 10 1 PARCEL:__Q"7" —ZONING DISTRICT: Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Y One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial 6XRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other ❑Septic Ll Well ❑Floodplain '0 Wetlands ❑ Watershed District ❑Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: An N5 Phone: q 7Sr'-771-k Jog A Address: CONTRACTOR Name: WkWd Peo.j-soN Phone: Address: 150 R, [eQlbZ)k4 0 p Supervisor's Construction License: 061% Exp. Date: j Home Improvement License: 07gG ` 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: $ 7 1 SO FEE: $ q q Check No.: i1399:7 Receipt No.: 3 i 3 10 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _/ ignature ofAgent/Ownerignature of contracto_ i MO' Plans Submitted ❑ Plans Waived Ell 0C.erMied Plot Plan ❑ Stamped Plans ❑ i TypF'OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/Massage/Body 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 PLANNING & DEVELOPMENT Reviewed On Signature_ � .COMMENTS CONSERVATION Reviewed on Signature I COMMENTS q i 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 Torn 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. ft.: ELECTRICAL: Movement of Meter location, mast or service drop, equires approval of Electrical Inspector lies No ®ANGER. ZONE LITERATURE: lies No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses i ❑ 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 i 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 N 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 act ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: 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:Building Permit Revised 2014 f -- L I I. � �1pRTl� own of ndover No. - ,� o S ver, Mass, COCMICNl WICK y1' �.95 RATE0 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ......�3h9.1R`� �� . � .......N�� 0 . �. ........................................................... BUILDING INSPECTOR Foundation p 37.3 A*1r#.!p..A...n.ov.tt.4J has permission to erect .......................... buildings on ... Rough to be occupied as ......S.T .A. .i. ........... ... ....�............................................................... Chimney sprovided that the person accepting 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 CONSTRUCTION START Rough Service ......... .. BUILDING...�.. .....................INSPECTOR................... Final GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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. f f r BLA64HLIN•1957@G-MIA-t'LdC,0,M— / LAUGHLIN HOMES INC. MASS REG. # MEMBER BETTER BUSINESS BUREAU FED ID # 41-2054365 MEMBER BEVERLY CHAMBER OF COMMERCE 9 Charles Street/RO. Box 252 MEMBER BEVERLY KIWANIS Beverly Massachusetts 01915 WARREN PEARSON CSL # CS40996 SINCE 1978rt / y�f (978) 922-5579 • (978) 828-3979 HIC t�i.�. # 107999 'SPECIFICATIONS SUBMITTED T9' 149 / j? 16,- PHONE: t .J ! /BOOB NAME: STREET: Q - CITY,STATE,ZIP: _ I V I i JOB LOCATION: JX, ! �� ARCHITECT: f DATE OF PI�r� r� JOB PHONE: .1 ✓q ✓t./�,✓ li ✓E'f,/ Installation of a complete Certainteed /-} , Shingle roof to the entire house. Gt'Y�E G ✓ IC. Inoclu&V4 II o�'ingles�we haul all debris, clean jobSlte thoroughly and pay all dump fees. ,,�, `Cl ,�- Includes Install: e S - ice and water membrane to main house eaves,.around chimney and in valleys - tarpaper.base and flanges to stacks - -- -- ` - - 8" aluminum dripedge to all edges. Color: tw/'j i ` � / ���r ✓ rsw - starter shingles to all rakes and fascias - cobra ridge vent to all heated ridge areastr6, y/.> ✓ o A-, 7 / Y7 /C-/l 4,1V6c - repair, reinforce as necessary and neatly seal chimney flashings, any step and apron flashings. - we procure permit, customer reimburses permit cost. -- ✓v c C[t rr'r 3 !J r?r✓ v' t C a'=,C L r,e`�-�'t 62 Option IL/ r /C <i.. '/ t't' - ► WbRe--rfi -we.aM11.go over-(no-stripping)-the-existing roof=arid-exel8des-ioearad-water s n, specifications as-above and tarpaper-base- / Col r: . �-7 96 0 ....�- . f' = N,Customer responsible to cover/tarp attic items and clean any resulting debris in°attic. Ten Year workmanship guarantee // t 611 11- A We Propose hereby to furnish material and labor-complete in acJordance with above specifications for the sum of. dollars(\$ ) _ Payment to be made as follows: 1/3 start, 1 and balance upon completion. Thank you. All material is guaranteed to be as specified.All work to be completed in workmanlike manner according to standard practices.Any alteration or deviation from above specifications involving Authorized extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our Signature: control.Owner to carry fire,tomado and other necessary insurance.Our workers are covered - by workers compensation insurance. Note:This proposal may be Owner agrees that in the event of his breach this contract before work started.Contractor may withdrawn by us if not accepted within days. demand twenty five percent(25""/0)of the contract price as its stipulated damages for the breach. Acceptance of Contract The above prices,specifications al d conditions are satisfactory and are hereby accepted.You are authorized to'do the work Sign as specified.Payment will be made as outli above. VDate of Acceptance / Signature You may cancel this Agreement 5f it has not been consummated by a party thereto at a place other than an address of the Seller,which may be his main office or a branch thereof,provided you notify Seller in writing at his main office or branch by ordinary mail posted,by telegram sent,or by delivery,not later than midnight of the third business day following the signing of this agreement. The.Commonwealth of Massachusetts Department of Industrial Accidents X Congress Street,Suite 100 Boston,MA 02114-2017 .J` www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'blv Name(Business/Organization/Individual): Address: ('so F- (,)i J�NO ��• City/State/Zip: tr1l LJ M,60 Phone#: Are you an emplover?Check the appropriate box: Type Of project(required): 1.A lama employer with ��employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, E]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.FJ t am a homeowner doing all Avork myself.[No workers'comp.insurance required.]t 10[]Building addition 4.F1 lam a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.FJ I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.g]Roof repairs These sub-contractors have employees and have workers'comp.insurance:- 6.F-1 we are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and Nye have no 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 this affidavit indicating they are doing all work and titen 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 air employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. jj,,�� r Insurance Company Name: vl JA Policy#or Self-ins.Lie.#: 5647 b 01 ExpirationDate: _ Job Site Address: 3-7-3 PZ4e_tr(h lALLrW �4 City/State/Zip: Attach a copy of the workers'compen tion policy declaration 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: t4e•.w �,�/ Date: Phone#: 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#: 6-12-08 13:59 EZOLOTAS 9787741318 >> P 1/1 DATE(MMIDDIYYYY) � CERTIFICATE OF LIABILITY INSURANCE 12/08/2016 HIS 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(les)must have ADDITIONAL INSURED provisions or 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 CONTACTElaine Zolotas Phil Richard Insurance, Inc. NAME: 27 Garden Street AJC No ExtI: 978-774-4338 FAX No: (978)774 1318 Unit 1B E-MA ss elaine@phildchardinsurance.com ADDRDanvers,MA01923 INSURER(S)AFFORDING COVERAGE NAIC p INSURERA: Utica First Insurance Company 15326 INSURED Pearson Builders, Inc. INSURERB: Arbella Protection Insurance Co 41360 150R Winona Street INSURERC: TRAVELERS A/R TRC Peabody,MA01960 INSURERD: INSURER E: 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. IPOLICY EFF POLICY EXP L R TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDIWW MM1DDIYYYY LIMITS A COMMERCIAL GENERAL LIABILITY ART5047208 11/28/2015 1/28/2016 EACH OCCURRENCE $ 1,000,000 DAM"CLAIMS-MADE OCCUR REMIS OR T 50,000 PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- ET F—] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY 1020004331 07/18/2016 07/18/2017 COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ 250,000 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ 500,000 HIRED NON-OWNED PROPERTY DAMAGE $ 100,000 AUTOS ONLY AUTOS ONLY Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION 7PJUB-2E10143-5-16 03/26/2016 03/26/2017 PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/E(ECUIIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? F7Y N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: 373 Raleigh Tavern Road CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE _-----> s ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD I j i PEARS-®N BUILDERS til contracw _ Wamm A.Pearmn R.Winn 5t Phone 978-7 W P VA91%9 Pax •` Massachusetts-Departinent of Public Safety Board of Building Regulations and Standards • CCanstl Li1Iar,Jt/pe!V liar License: CM -(M _ ARREitl 11 d'L_'A t� 15OR WINONA PEABODY MA @1966'" Expiration Commissioner 04/1212097 �... :Jlic Y'ouiuic=lttnenf/�Gjl�•l�iiJ..uc�tiJ!/r' — - Office of Consumer Affairs&Business Reaulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 107999 T Office of Consumer Affairs and Business Regulation l. Expiration::-:;8111/2018 Individual 10 Park Plaza-Suite 5170 Boston,IVIA 02116 WARREN A PEARSON` - Warren Pearson 15OR Winona St. Peabody,MA 01960 Undersecretary Not valid without si nature g 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS I DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no j Located at 124 Main Street Fire Department signature/date COMMENTS A i Location 373 e A 10 t ti A 14 y Kxv-j P -6 No. (04 ( - :101 '7 Date f 8 ' ;�-01(a • - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# J 10 / Building Inspector