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HomeMy WebLinkAboutBuilding Permit #234 - 394 BOSTON STREET 9/25/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: S--0 IM RTANT:Applicant must complete all items on this page LOCATION �1 Print PROPERTY OWNER e f C,-GG <' -Print MAP NO:/ PARCEL: ZONING DISTRICT: Historic District yeno Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building Oe family Addition family Industrial Alteration No. of units: Commercial Repair replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 5tlaw Identification Please Type or Print Clearly) OWNER: Name: fol—* e,, 421--1,4lP1 Phone: 6 �?3 Address: o CONTRACTOR 'Name: r &_q Phone: Address: . Supervisor's Construction License: 2- 962 Exp. Date: Home Improvement License: /A 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 d�y FEE: $ Check No.: 0 v Receipt No.:Kfe,�K�-, NOTE: Persons co tracting with unregistered contractors do not have access o the guaranty fund Signature of Agent/Owner Signature of contractor Location Zos ✓1 No. Date " MaRTM TOWN OF NORTH ANDOVER F w A Certificate of Occupancy $ MUs t�' Building/Frame Permit Fee $ ��o Foundation Permit Fee $ Other Permit Fee $ w TOTAL $ Check # 22441 ) - J Building Inspector i 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 i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT I COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature d i 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: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS tAORTH TO" of : t 4Andover 0 No. 2� AKE = dover, Mass., COCMICMEWICK y�• ADRATED 10f, �y `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT. Pie r ''�J � Foundation has permission to erect............ .. ......... buildings on / ,. ZX �..... ./7 av • Rough ......................... to be occupied as 0 .. ............................................................................................... Chimney �'� 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 Final �d PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTIO ST ELECTRICAL INSPECTOR -Rough ................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance ors special permit was required the Town Clerks office must stamp the decision from the Board of Appeals P P 4 P PP 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 2008 The Commonwealth of Massachusetts Department of Industrial Accidents Saw Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): S Address: V 2 City/State/Zip: A-19-- Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.�? I am a employer with 4. a I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors ❑ 2.❑ I am a sole proprietor or partner- listed on the attached sheet. EJ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 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.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *A:i' that checks box n1 must also LII out the section below shoving their workers'compensation policy information. y arr � t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy#or Self ins.Lic.#: A/,y� D l _ n D/ 7 Expiration Date: .2 Job Site Address:4?q ! G0.9Z_o_v C7— City/State/Zip: A,`, ,9A-,0a 41,p 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: —d I Phone#: i 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#: �® CERTIFICATE OF LIABILITY INSURANCE OP ID GM DATE(MM/DD/YYYY) AMERB01 09/16/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CHARLES J COUGHLIN ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE INSURANCE AGENCY HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 DINLEY ST. P.O.BOX 10 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. DRACUT MA 01826-0010 Phone: 978-957-3588 Fax:978-957-6612 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Ins Co 14788 INSURER B: AIM Mutual Ins. Co. American Business Services Bob Lamothe & Ed Sager INSURER Safety Insurance Company 33618 28 Lakeshore Drive INSURER D: Dracut MA 01826 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE DATE MM/DD/YYYY DATE MMIDD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. luKtN A X COMMERCIAL GENERAL LIABILITY MP073317 08/03/09 08/03/10 PREMISES(Ea occurence) $500,000• CLAIMS MADE Fx—1 OCCUR MED EXP(Any one person) $ 10,000. PERSONAL&ADV INJURY $ 1,000,000. GENERAL AGGREGATE s2,000,000. GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000. POLICY M PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 C ANY AUTO 6204620 10/20/08 10/20/09 (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTOEA ACC $ OTHER THAN _ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR El CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION - - AND EMPLOYERS'LIABILITY X TORY LIMITS ER YIN B ANY OFFICER/MEMBEREXRTNER/?ECUTIV4----I AWC7016440012007 02/16/09 02/16/10 E.L.EACH ACCIDENT $ 500,000. (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000. If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000. OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Interior Painting, Remodeling, Fence Installation, Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION PEROCCH DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Joyce Perocchi REPRESENTATIVES. 394 Boston Street N Andover MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts- Department of Public SafetN Board of Buiidinl- Re!,ulations and Standards Construction Supervisor License License: CS 79413 Restricted to: 00 EDMUND L SAGER Al, 216 WENTWORTH AVE LOWELL, MA 01852 Expiration: 5/18/2011 (lnumi> inncr Tr#: 4564 i f ABS AMERICAN BUSINESS SERVICES pAINpING DECORATING PAINTING AND REMODELING CONTRACTORS CONTRACTORS OF Commercial and Residential 1AMERICA 4 28 Lakeshore Drive (978) 7640523 Dracut, NIA 01826 This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A). Any person planning home Improvements should first obtain a copy"A Consumer Guide to the Home Improvement Contractor Law" before agreeing to any work on your residence.The guide will inform you of your rights and responsibilities as well as provide you with important information about what to do if a dispute arises.You may obtain a free copy by calling the Executive Office of Consumer Affairs'Information Hotline at 617-727-7780. Homeowner Information Contractor Information Name Company Name Street Addr s(Do not use a Post Office Box address) Contractor/Salesperson/Owner Name J © O Cityfrown State Zip Code Business Address(Must include a street address) /V1 d/1-1 /L 0,4 Daytime Phone Evening Phone �}+ City/Town State Zip Code lsa F D �c7�/ Mailing Address(If different from above) Business Phone Federal Employer ID or S.S.Number 01/ _, FyPL'aTi requires that all home im- Home improvement Contractor Reg.Number Expiration Date vement contractors have a d re istradc number. The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to be completed,specifying the type,brand and grade of materials to be used.) c Z ❑Check this box if additional pages are used for this section. Required Permits - The following building permits are required Proposed Start and completion schedule - The following schedule will be adhered to unless and will be secured by the contractor as the homeowner's agent. circumstances beyond the contractor's control arise. Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A. -Date when contractor will begin work. -Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: $ ��. D " E Payments will be made according to the following schedule: $ % 00 M upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greaterz). � 19 $ / 60 by or upon completion of 'v/ $ / A— by or upon completion of $ < < ® 0 upon completion of the contract.(Law forbids demanding final payment until contract is completed to both party's satisfaction.) The following material/equipment must be special $ 1_1�� to be paid for ordered before the contracted work begins in order to meet the completion schedule.2 $ to be paid for NOTES:(1)Including all finance charges (2)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor) KNo ❑Yes(all terms of the warranty must be attached to the contract) Subcontractors -The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor.The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document, this contract shall not imply that any lien or other security interest has been placed on the residence.Review the following cautions and notices carefully before signing this contract. • Don't be pressured into sighing the contract.Take time to read and fully understand it. • Make sure the contractor has a valid Home Improvement Contractor Registration.The law requires all home improvement contractors and subconttactors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the director at One Ashburton Place,Room 1301,Boston MA 02108 or by calling 617-727-8598 or 617-727-3200. • Does the contractor have insurance?While it is not required by law,it is a good idea and an additional protection. • Know your rights and responsibilities.Read the important information on the reverse side of this form and get a copy of the Consumer Guide. E cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the r in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of business day following the signing of this agreement.See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! f2, ' 2 0 11) ��� `�J � dor owner's Signature Date Contractor's Sig re Date 1lassachusetts- Department of Public SafelN Board of Buildim- Re�-uiations and Standards Construction Supervisor License License: CS 79413 Restricted to: 00 EDMUND L SAGER 216 WENTWORTH AVE LOWELL, MA 01852 �--�--�/ Expiration: 5/18/2011 C.,film issio ule I Tr#: 4564 ✓fie -�aminw�zurea�i o�✓l�acfitceeka Board of Building Regulations and Standards Construction Supervisor License License: CS 28809 Expiration: 5/14/2010 Tr# 24683 Restriction: 00 ROBERT A LAMOTHE 28 LAKESHORE DR �--�- DRACUT,MA 01826 Commissioner - _ { B(&o s anaan,ar�s . -\ HOME IMPROVEMENT CONTRACTOR Registration: 127887 -- Expiration:--__1/25/2011 Tr# 278698 Type Partnership AMERICAN BUSINESS SERVICES ROBERT LAMOTHE- 28 LAKESHORE DR DRACUT,MA 01826` __ Administrator i I